The Fifth Circuit has issued its ruling in TMA III, a major reset for how qualifying payment amounts must be calculated under the No Surprises Act.
Ghost rates must come out. Bonus and incentive payments must go in. The agencies' prior guidance, the court found, materially distorted QPAs. Single-case agreements can still be excluded.
The opinion ties these errors to the record so far: providers prevailed in over 80 percent of disputes, and the prevailing reimbursement rate was higher than the QPA in 85 percent of arbitrations.
